MEDICAL PLANS

$800 PPO PLAN 1	In-Network	Out-of-Network
Deductible Individual/ Family	$800 / $1,600	$1,000 / $2,000
Out-of-pocket maximum	$7,900 / $15,800	$15,800 / $31,600
Coinsurance	80%	60%
Preventative Care	$0	Deductible & Coinsurance
Primary care office visit	$20 Copay	Deductible & Coinsurance
Specialty offcie visit	$40 Copay	Deductible & Coinsurance
Urgent Care Visit	$40 Copay	Deductible & Coinsurance
Inpatient hospital service / Outpatient surgery	Deductible & Coinsurance	Deductible & Coinsurance
Lab services	Deductible & Coinsurance	Deductible & Coinsurance
MRI, MRA, CT and PET scans	Deductible & Coinsurance	Deductible & Coinsurance
Emergency room	$150 Copay	Paid as In-Network
X-rays	Deductible & Coinsurance	Deductible & Coinsurance
Prescription drugs Tier 1 / Tier2 / Tier 3	$5/20% to $100/40% to $150/50% to $750	$5/20% to $100/40% to $150/50% to $750
Lifetime maximum	Unlimited	Unlimited

Bi-Weekly Cost	$20 AHY DISCOUNT	$10 AHY DISCOUNT	$5 AHY DISCOUNT	NO AHY DISCOUNT
EMPLOYEE	$67.81	$77.81	$82.81	$87.81
EMPLOYEE + SPOUSE	$232.87	$242.87	$247.87	$252.87
EMPLOYEE + CHILD(REN)	$173.17	$183.17	$188.17	$193.17
FAMILY	$338.24	$348.24	$353.24	$358.24